By Eliza Marie Somers

Putting the brakes on chronic pain is no easy task, and “living with it” is no way to live. Chronic pain can last for months even years and affects all parts of the body. It can lead to depression, anxiety, social isolation, along with an addiction to pain medications. After a brain injury the odds of experiencing chronic pain increase as a study published earlier this year revealed. An article in the Journal of Head Trauma Rehabilitation stated that chronic pain affects about 60 percent of traumatic brain injury survivors.

To help brain injury survivors, the Brain Injury Hope Foundation’s Survivor Series on June 14, 2024 focused on Chronic Pain Management with a panel of caregivers who offered ways to manage and mitigate pain.

The panel included:

  • Nancy Bonifer, PT, DPT, MS
    Dynamic Recovery Physical Therapy
    6901 S. Pierce St.  #320
    Littleton, CO 80128
    303-872-7240
  • Perry Maynard, DC, DACNB
    Integrated Health Systems
    3601 S Clarkson St.
    Englewood, CO 80113
    303-781-5617
  • Kelsy Rayl, PT, DPT
    Sparq Physical Therapy
    755 S Perry St Suite 450
    Castle Rock, CO 80104
    720-463-4752
  • Eric Dorninger, ND, LaC
    183 S Taylor Ave Suite 158
    Louisville, CO 80027
    303-449-9494

“Pain is just an emotional response to a threat,” Dr. Perry Maynard said.

“The body is saying, something is not right in my environment,”

And knowing what type of pain a patient is experiencing is vital to the care and therapies administered to a client. Maynard noted there are different subclasses of pain.

Peripheral pain, which is outside of the spinal cord, includes inflammatory pain, ischemic pain that is from decreased blood flow to the nerve and neuropathic pain, which is when the nerves become over sensitive as in diabetic pain. And there is central pain, which is a chronic sensation in the brain, and includes central sensitization pain, autonomic pain and affective pain.

Dr. Perry Maynard says there are subsets of pain and knowing what type of pain a patient is experiencing is vital to the proper care.  

“We really need to understand the pain and the threat,” Maynard said. “Is the pain still in the peripheral of the body or has it moved to the brain where the way a person is receiving the threat is altered?”

Maynard said he also looks at the emotional side of pain, and how anxiety and depression play a role. “When you look at imagining studies of the spine, we know that degeneration or tissue damage is not equal to the pain that one experiences because there is a huge emotional aspect around pain.

“We listen to a patient’s language, and how does one speak about their pain,” he explained. “Is it empowering or is it: I’ll never get over this. It’s really important to understand how they feel about their pain, and what they think it is actually doing to them.”

Physical therapist Dr. Nancy Bonifer said educating people plays an important role in managing chronic pain. “Education is a huge part of understanding your condition and empowering patients on how they can manage their symptoms,” she said. Along with teaching clients Bonifer utilizes manual therapies and modalities that decrease pain, including dry needling, vestibular work, warm pool water therapy and kinesiology taping. 

Dr. Nancy Bonifer says educating a patient is a big part of care.

Dr. Kelsy Rayl, a physical therapist who specializes in vestibular issues, agreed education is an important piece to helping the patient understand their pain. She described how the brain maps your body and how it understands the different body parts, which can become “muddied or blurred” when one is dealing with chronic pain.

“An example is shoulder pain,” she said, “and now it’s the upper back and neck that are painful because the map of those distinct areas, those lines have become blurred. As those inputs of pain now have become so consistent it changes your nervous system functions and how it perceives that pain and where that pain is located. We help to refocus that map.”

Dr. Eric Dorninger added that treating inflammation in the brain after a head injury is crucial to calming the pain cycle.

“When you get a concussion, you turn on these immune cells in your brain. Those are inflammatory cells or microglia cells in the brain, and they are hard to turn off,” Dorninger explained. “You have to go all in.

“Concussion patients also have higher rates of apnea. … When sleeping, the patient is choking on oxygen, and that will make you more inflammatory…. Anything that corrupts oxygen, which is the No. 1 physical ingredient for life, is a problem.

  • Didgeridoo for Sleep Apnea

https://www.youtube.com/watch?v=ZJ82RrXUkQc

https://www.youtube.com/watch?v=gbRlA2KeUzE

https://drdorninger.com/sleep_apnea_podcast/

“There are basically three bosses in the body:  the brain, the immune system and the endocrine system. And they all tell each other what to do, but once those microglia cells turn on, you are now an inflammatory patient. You have to dig deeper into how to get those microglia cells to turn off, so that the work you are doing, whether exercising or working with a PT, actually holds.”

Dr. Eric Dorninger is also director or research and development with Blus Sky CBD

Along with his practice, Dorninger is the director of research and development for  Blue Sky CBD, and he is “excited” about the possibilities for healing with the cannabidiol and isolates in hemp plants. Dorninger said he agreed to work with Blue Sky because the company met his three criteria for CBD – third-party testing for purity and potency, zero THC and price per milligram per CBD.

  • Blue Sky CBD

https://www.bluesky-cbd.com/

“Really exciting stuff with regards to brain health and full body pain management with cannabidiols,” he said. “In 20 years in natural medicine nothing has worked better for pain or quicker than cannabidiol and isolates. It can be exciting for people.”

Back to the immune cells in the brain and their hyperactivity after a TBI, Dorninger said, “Where cannabidiols come into this is it’s a novel anti-inflammatory that does not destroy the liver, kidney or intestinal lining.”

He also noted that when the brain is on fire from inflammation “you now have more anxiety… so when you look at any mood disorder, they all have high inflammatory signs. You have to take an approach that looks at internal inflammation along with the biomechanics.”

https://www.youtube.com/watch?v=BbgSCrps6bM&t=3123s

All the panelist agreed communication is key to receiving the proper care. And that communication goes both ways.

Rayl says she tells TBI and chronic pain clients what to expect when starting treatments so they “don’t become scared because the nervous system is on edge.”

Dr.Kelsy Rayl says a reasonable amount of pain can be expected when working with a provider.

“In the chronic pain phase, the brain’s been compensating for a long time, and now we are going to change the picture. And the brain – it might not like it as we work on the underlying deficit,” Rayl explained. “We are changing what the nervous system is used to and the nervous system might feel threatened and may cause the symptoms to increase. That is reasonable as long as we keep it in range and work through that and adjust the treatment plan.”

Perry said, “I always tell patients we may provoke some symptoms because we are learning your fatigue point, and fatigue point is huge. I tell patients pay attention to symptoms, but that symptom provocation is not always a bad thing. It doesn’t mean you are getting worse. It’s our role as a provider to educate the patient. The better they understand what’s going on than they can de-escalate.”

Bonifer stressed patients need to know their medical history and relate that information to their providers.

An example she share with us: a chronic pain patient comes in with foot pain and says they had foot surgery five years ago but doesn’t remember what the doctor did in surgery.

“So, let’s say I want to mobilize or manipulate the foot, and the foot was fused together, that would be a counterindication. Knowing your own medical history is very, very important,” Bonifer explained.

Clients also need to relate if they have any sensitivities, such a light or sound sensitivities. “I tell people I need their feedback. I won’t be offended if you tell me I made you feel bad on accident. I need to know that so I can adjust. If you don’t tell me I’m just working off guesses,” Rayl said.

Knowing your medications and supplements also is key to treatment, as some medications, such as fat-soluble statins, can cause pain, while others, such as Benadryl, can raise your risk of mild cognitive impairment, Dorninger said. “You have to do an evaluation of the drugs and supplements someone is taking. Just because it’s natural does not mean it’s not harmful.”

He stressed the importance of patients telling providers all the over-the-counter drugs, supplements, prescription drugs AND recreational drugs they are consuming. 

A patient also should evaluate their providers, by asking other TBI and chronic pain sufferers for recommendations, and then asking their providers questions about their backgrounds and modalities.

“Instead of trying to fit individuals into a box, what we (providers) need to do is figure out what modality is best for the patient,” Perry said. “Are (providers) really tailoring this treatment around me? You have to have a provider that is well-rounded but also know their limitations.”

Someone who is capable of telling a patient, “Hey, I don’t know, but I know this really great doctor who would be really good for you,” Perry said. “That’s really the point of a provider is to help an individual, but to also get the patient to the right doctor at the right time to help save them money.”

This might lead a patient to put together a “dream team” of healthcare providers. And when choosing professionals, Bonifer offered a few suggestions on seeking the right team members.

Bonifer stressed knowing what your goals are and what type of environment you work best in when it comes to care.

“Thinking about the environment you want to be treated is important. Do you do better in a one-on-one environment where you always see the same practitioner? Some people do better in a busier/louder environment. And you have to interview your provider to find out what their approach is. What’s their familiarity in treating your condition. And location is always an issue. Accessibility,” Bonifer said.

Having a positive healthcare provider also can make a huge difference in care as Perry explained some doctors feed into a patient’s gradualness, as patients begin to believe they can’t do certain things because they are fragile.

“We are far more durable than what people tell us we are. I see a ton of fragile patents, people bedridden, people who can’t walk, and if we continue to feed into them not being durable or strong, their mindset will never change. Being able to write that empowering narrative for them is important. They might not have that hope, and you as the provider have to hold that for them. In six months, they might now see that new story that they can write.

“There is hope. A lot people go to lot of providers and quickly lose hope,” Perry said. “There are so many good providers out there. Maintain hope. Advocate for yourself.”

Bonifer added, “Be patient and be consistent. Often there’s not a quick fix, often it can take quite a bit of time and effort and lifestyle changes, too. Improvement and real change can happen.”

Environmental Toxins, TBI and Chronic Pain

Environmental toxins can play a huge role in the underlaying problem of chronic pain. Dr. Eric Dorninger said 60 percent or more of his practice is dealing with chronic inflammatory response syndrome or CIRS.

CIRS is due to exposure to mold in water damage buildings, sewer gas, algae ponds and even the food we eat. “We are starting a research trial where we look at TBI brains and CIRS brains. To see if there is overlap in atrophy brains. CIRS, TBI and traumas all can atrophy the brain. The CIRS side of things are treatable, and does that translate to TBI patients?”

Dorninger stressed that if a provider is treating a TBI or chronic pain patient, but the patient lives in a toxic environment or has a toxic lifestyle, the treatments will not stick if environmental changes are not made.

He also explained that inflammation patterns are almost the same in TBI, CIRS and trauma patients. “Where the CBD come in is with CIRS, TBI and other inflammatory conditions, you deplete your body’s natural cannabidiols.”

Neurological disorders and chronic pain also can be caused by the food we eat. Dorninger cited Chilean sea bass as an example of a food that can lead to neurological problems from ciguatera fish poisoning.

“When you eat sea bass that is infected with ciguatera your get a massive insult to your brain where hot feels cold and cold feels hot. And now you start the journey of dementia. There is medicine to treat that, but we are not taught to look for it,” he said.

“We need to reinstall curiosity in understanding the underlying cause of chronic pain,” Dorninger said.